Healthcare Provider Details

I. General information

NPI: 1497724157
Provider Name (Legal Business Name): CLYDE DODSON PAULK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 OPPORTUNITY DR
SHERIDAN AR
72150-9185
US

IV. Provider business mailing address

21 OPPORTUNITY DR
SHERIDAN AR
72150-9185
US

V. Phone/Fax

Practice location:
  • Phone: 870-942-9833
  • Fax: 870-942-9837
Mailing address:
  • Phone: 870-942-9833
  • Fax: 870-942-9837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC3204
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: